“Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does.” Health practitioners must rely on the patient’s description of the pain because it is a subjective symptom that only the patient can identify and describe. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

Acute pain

is generally rapid in onset, varies in intensity from mild to severe. It is protective in nature; that is, it warns the individual of tissue damage or organic disease. After its underlying cause is resolved, acute pain disappears. It should end once healing occurs. Causes of acute pain include a pricked finger, sore throat, or surgery.

Chronic pain

is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. The most recent definition of chronic pain no longer mentions the previous guideline of 3 to 6 months duration for pain to be considered chronic.

remission

Commonly, people with chronic pain experience periods of remission; when the disease is present but the person does not experience symptoms.

exacerbation

Commonly, people with chronic pain experience periods of exacerbation; the symptoms reappear.

chronic malignant pain

Pain associated with cancer or other progressive disorders.

chronic nonmalignant pain

Pain in people whose tissue injury is nonprogressive or healed.

Cutaneous pain

superficial pain, usually involves the skin or subcutaneous tissue.

Deep somatic pain

is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

Visceral pain

is poorly localized and originates in body organs in the thorax, cranium,and abdomen. This pain occurs as organs stretch abnormally and become distended, ischemic, or inflamed.

reflex contraction or spasm of the abdominal wall, called gaurding

may occur as a protective mechanism to prevent additional trauma to underlying structures. An individual automatically tenses their abdomen when an acute abdominal pain condition is present. This prevents underlying tissues and organs from being palpated or touched.

referred pain

Pain can originate in one part of the body but be perceived in an area distant from its point of origin. Pain associated with a myocardial infarction, or heart attack, is frequently referred to the neck, shoulder, or arms (often the left arm). Referred pain is transmitted to a cutaneous (skin) site different from where it originated. This is possible because the pain can travel to other areas of the body innervated by the affected nerve root.

Neuropathic pain

results from an injury to or abnormal functioning of peripheral nerves or the central nervous system. The exact cause of neuropathic pain is unknown,and it can occur in many forms. Neuropathic pain can be of short duration or lingering and is often described as burning or stabbing.

Allodynia

a characteristic feature of neuropathic pain, is pain that occurs after a normally weak or nonpainful stimuli, such as a light touch or a cold drink.

Complex regional pain syndrome (causalgia)

Pain occurs in the area of a partially injured peripheral nerve (the most common lesions are of the brachial plexus or median or sciatic nerve). The pain is described as burning, severe, diffuse, and persistent and iselicited by minimal movement or touch of the affected area. It increases with repeated stimulation and continues even after stimulation ceases.

Postherpetic neuralgia

Pain syndrome follows an acute central nervous system infection, such as herpes zoster (shingles). The herpes syndrome is characterized by a vesicular eruption and neuralgic pain, which is usually unilateral and encircles the body in band-like clusters. The severity of the pain may be mild to severe. Intractable pain may persist for months to years.

Phantom limb pain

Pain that may occur in any person who has had a body part amputated either surgically or traumatically. Pain varies and may be a severe, burning, fiery sensation; crushing; cramping; a sense that the limb is edematous; or a sensation that the limb is being twisted and distorted. It may be triggered by the sensation of touching the stump, the occurrence of another illness, fatigue, atmospheric changes, and emotional stress. (The pain that is often referred to an amputated leg where receptors and nerves are clearly absent is a real experience for the patient. This type of pain is called phantom pain or phantom limb pain and is without demonstrated physiologic or pathologic substance. One theory suggests that sensory misrepresentations from the missing limb may still remain in the brain thereby causing phantom pain.)

Trigeminal neuralgia

Paroxysms of lightning-like stabs of intense pain in the distribution of one or more divisions of the trigeminal nerve, the fifth cranial nerve. Pain is usually experienced in the mouth, gums, lips, nose, cheek, chin, and surface of the head and may be triggered by everyday activities like talking, eating, shaving, or brushing one’s teeth.

Diabetic neuropathy

A common complication of long-term diabetes mellitus. Metabolic and vascular changes result in damageto peripheral and autonomic nerves. Sensory loss can result when peripheral nerves are involved andeventually lead to injury progressing to infection and gangrene. Symptoms include sensations of numbness, prickling, or tingling (paresthesias).

intractable

When pain is resistant to therapy and persists despite a variety of interventions. Nurses and physicians together need to determine the appropriate pain treatment for each case of intractable pain so that an individual can regain a healthy quality of life.

psychogenic pain

Pain may also have a psychogenic origin, meaning that a physical cause for the pain cannot be identified. However, it has been observed that a pure origin is probably rare, and pain usually has both physical and psychogenic components. Furthermore, pain that results from a mental event can be just as intense as pain that results from a physical event.

The activation of pain receptors. It involves conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn. Additionally, when the threshold of perception for pain has been reached and when there is injured tissue, it is believed that the injured tissue releases chemicals that excite or activate nerve endings. For example, a damaged cell releases histamine, which excites nerve endings. Lactic acid accumulates in tissues injured by lack of blood supply and is believed to excite nerve endings and cause pain or to lower the threshold of nerve endings to other stimuli (e.g., heat or pressure). The prolonged effect of pain stimuli acting on the central nervous system can lead to sensitization, meaning that the threshold for activation of pain is lowered. At that point, even harmless stimuli can trigger pain; pain signals are faster and feel more intense. Other substances are also released that stimulate nociceptors or pain receptors. These include bradykinin, prostaglandins, and substance P.

Bradykinin

a powerful vasodilator that increases capillary permeability and constricts smooth muscle, plays an important role in the chemistry of pain at the site of an injury even before the pain message gets to the brain. It also triggers the release of histamine and, in combination with it, produces the redness, swelling, and pain typically observed when an inflammation is present.

Prostaglandins

are hormone-like substances that send additional pain stimuli to the CNS.

Substance P

sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves.

Prostaglandins, substance P, and serotonin are neurotransmitters or substances that either excite or inhibit target nerve cells.

mechanical stimulants

Friction from bed linens and pressure from a cast

thermal stimulants

Sunburn and cold water on a tooth with caries

chemical stimulant

An acid burn

electrical stimulant

The jolt of a static charge

transmission

Pain sensations from the site of an injury or inflammation are conducted along pathways to the spinal cord and then on to higher centers. These pathways are rather clearly defined in certain areas, but are still somewhat unclear in other areas. The overall process is known as transmission. No specific pain organs or cells exist in the body. Rather, an interlacing network of undifferentiated free nerve endings receives painful stimuli. Free nerve ending pain receptors include the afferent fast-conducting A-delta-fibers and the slow-conducting C-fibers. The larger A-delta-fibers transmit acute, well-localized pain, whereas the smaller C-fibers convey diffuse, visceral pain that is often described as burning and aching. It is estimated that there are several million of these nerve endings in the body, numerous in the layers of the skin and in some internal tissues, such as the joint surfaces. In the deeper tissues of the body, the pain receptors are diffusely but unevenly spread.

afferent

those fibers carrying impulses from the pain receptors toward the brain

protective pain reflex

is responsible for withdrawal of an endangered tissue from a damaging stimulus. Sensory impulses travel over A-fibers through the dorsal root ganglion to the dorsal horn of the spinal cord. At this point, the sensory nerve impulse synapses with a motor neuron, and the impulse is carried along efferent nerve pathways back to the site of the painful stimulus in a reflex arc. This results in an immediate muscle contraction that removes the injured part from the source of the pain.

perception

The perception of pain involves the sensory process that occurs when a stimulus for pain is present. It includes the person’s interpretation of the pain.

pain threshold

The threshold of perception is the lowest intensity of a stimulus that causes the subject to recognize pain. This threshold is remarkably similar for everyone, but some studies have reached the conclusion that women have lower thresholds than men. The possibility that men and women have different expectations relative to pain perception may be a contributing factor to pain threshold. Still, it is theorized by at least some authorities that the phenomenon of adaptation does occur, that is, the pain threshold can be changed within a certain range. This phenomenon has been studied, for example, when prisoners of war reported that the pain of repeated torture was not as acute as it would have been under different circumstances. Many factors might well have played a role, but at least some adaptation appears likely.

modulation

The process by which the sensation of pain is inhibited or modified. The sensation of pain appears to be regulated or modified by substances called neuromodulators.

neuromodulators

are endogenous opioid compounds, meaning they are naturally present, morphine-like chemical regulators in the spinal cord and brain. They appear to have analgesic activity and alter the perception of pain. These endogenous opioid compounds are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the CNS, blocking the release or production of pain-transmitting substances. Both pain and stress appear capable of activating the endogenous opiate system. Endorphins and enkephalins are opioid neuromodulators.

Endorphins

are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is suggested that endorphins maybe released when certain measures are used to relieve pain, such as skin stimulation and relaxation techniques, and when certain pain-relieving drugs are used.

dynorphin

The endorphin, dynorphin, has the most potent analgesic effect.

gate control theory

Many theories have attempted to explain the mechanism of pain. However, the gate control theory provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a relation between pain and emotions. The theory states that certain nerve fibers, those of small diameter, conduct excitatory pain stimuli toward the brain, but nerve fibers of a large diameter appear to inhibit the transmission of pain impulses from the spinal cord to the brain. There is a gating mechanism that is believed by some to be located in substantia gelatinosa cells in the dorsal horn of the spinal cord. The exciting and inhibiting signals at the gate in the spinal cord determine the impulses that eventually reach the brain. Thus, only a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells in the spinal column interrupt the signal as if closing a gate. The brain can also influence the gating mechanism. Past experiences and learned behaviors, which are interpreted by the brain, regulate or adjust the eventual behavioral responses to pain. Thus, the gating mechanism appears to be influenced by the amount of activity in large and small afferent fibers in addition to nerve impulses that descend from the brain. This helps explain why similar painful stimuli are interpreted differently by different people. Although not everyone accepts the gate control theory, it appears to explain why mechanical and electrical interventions or heat and pressure may provide effective pain relief. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area.

Sharp

Pain that is sticking in nature and that is intense.

Dull

Pain that is not as intense or acute as sharp pain, possibly more annoying than painful. It is usually more diffuse than sharp pain.

Diffuse

Pain that covers a large area. Usually, the patient is unable to point to a specific area without moving the hand over a large surface, such as the entire abdomen.

Shifting

Pain that moves from one area to another,such as from the lower abdomen to the area over the stomach.

These terms depend on the pt's interpretation of pain. Behavioral and physiologic signs help assess the severity of pain. On a scale of 1 to 10, slight pain could be described as being between about 1 and 3; moderate pain, between about 4 and 7; and severe pain, between about 8 and 10.

Continuous

Pain that does not stop.

Intermittent

Pain that stops and starts again.

Brief or transient

Pain that passes quickly.

Cultural norms

Cultural norms dictate much of our daily behavior, attitudes, and values. Therefore, it is natural that culture influences the individual’s response to pain. Nurses need to understand that there are ways other than their own of responding to pain. Nurses, as a subculture, value self-control and the ability to function under stress. As a result, nurses may expect patients in pain to display a similarly calm, objective, uncomplaining approach to pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters patients who are in pain or anticipating that it will develop. A form of pain expression that is frowned on in one culture may be desirable in another cultural group. Be knowledgeable about cultural variations and develop an understanding of cultural influences on pain tolerance, expressions of pain, and alternative practices used to manage pain.

Ethnic Variables

The classic study on behavioral responses to pain in people of similar ethnic origin was done. Studied men in the 1950s and 1960s in four cultural groups—“Old American” (American-born, white, Protestant, and without identification with any foreign group), Jewish, Italian, and Irish. Old American and Irish men typically minimized and controlled their expression of pain, whereas Jewish and Italian men tended to be more vocal and outwardly emotional with their expressions of pain. Today, the ethnic heritage of many people is mixed, thereby making it more difficult to anticipate individual responses to pain. Healthcare providers increase their respect and sensitivity for diversity if they understand the effects of culture and ethnicity on the pain experience. The nurse working with other ethnic groups can find pertinent studies in the literature and on various web sites.

African Americans response to pain

Often viewed as a sign of illness or disease.

Some believe that suffering and pain are inevitable.

Spiritual and religious beliefs may contribute to high tolerance for pain.

Some believe that praying and laying on of hands may aid in deliverance from pain and suffering.

Arab Americans

Often view pain as unpleasant and something that should be controlled.

Tend to express pain openly with family members but may act in a more restrained manner in the presence of health professionals.

Usually expect positive response from Western medical interventions to control pain.

Chinese Americans

Expressions of pain are usually similar to those of Americans.

Often believe pain is related to the influence of imbalances in the yin and yang.

Usually cope with pain by using externally applied oils and massage as well as warmth, sleeping on the area of pain, relaxation, and aspirin.

Greek Americans

Ponos (pain) is viewed by most as an evil that needs to be eradicated.

Physical and emotional pain are usually shared with the family.

Family is considered a resource for pain relief because they act as advocates and provide emotional support.

Mexican Americans

Most delay seeking medical help for pain and hope, instead, that it will go away; consider it a necessary part of life.

Seem to experience more pain than other ethnic groups but report it less frequently.

Often see a direct relationship between pain and suffering and immoral behavior.

Navajo Indians

Do not usually openly express their pain or request pain medication.

Adequate pain control is often difficult because they may mask the actual intensity of their pain.

May prefer herbal medicines and use them without the knowledge of the healthcare provider.

Family, Gender, and Age Variables

An individual’s response to pain or symptoms may be affected or influenced by the response of family members. Spouses also may reinforce pain behavior in their partners. Children growing up in different families may learn to “be brave” and ignore pain or to use the pain experience to secure attention and service from family members. Family size and birth order do not appear to be significant in distinguishing chronic pain sufferers. Similarly, children may learn that there are gender differences in pain expression—it may be acceptable for a little girl to run home crying with a scraped knee, but a little boy may be told that he should be brave and not cry. Adult men and women may hold on to gender expectations regarding pain communication and incorrectly interpret the presence or absence of pain expressions in others. Women are more comfortable communicating the discomfort associated with pain, but this ability to verbalize may cause some to view the pain as emotionally or psychologically based. Several studies report that pain in women needs to be addressed more aggressively because their pain management is consistently reported as inadequate. In addition, different age groups have different beliefs and norms regarding pain sensation and response. At one time, the infant’s inability to communicate pain led healthcare practitioners to the erroneous assumption that pain sensation was diminished or absent. More recently, it has been demonstrated that infants and small children are sensitive to and experience pain. Among older people, pain has often been viewed as a natural component of the aging process, being ignored or undertreated by healthcare providers. On the other hand, conditions normally painful in young adults (e.g., myocardial infarction) may result in minimal pain complaints in older people. That an older person does not complain of pain may indicate that he or she fears the treatment for the pain or just refuses to give in to the pain. For many older adults, pain has become accepted as a daily occurrence and is regarded as part of the normal aging process. These variables, which influence pain sensation, perception, and response, make pain assessment a complex task for the nurse.

Religious beliefs

In some religions, individuals view pain and suffering as a “lack of goodness” in themselves. Thus, pain and suffering are viewed as a means of purification or of making up for individual and community sin. This meaning helps the individual to cope with pain, thus becoming a source of strength. Patients with this belief may refuse analgesics and other pain relief measures, feeling that this lessens their suffering. On the other hand, illness and pain may also be viewed as punishment from a vengeful God. Individuals may find their faith shaken and question the existence of a loving God. How can belief in a loving God be compatible with their present experience of pain? Anger, resentment, and depression may compound the pain experience. Patients may find it helpful to confer with a spiritual adviser about their pain experience.

The Joint Commission (TJC), in an effort to improve pain management, also developed accreditation standards that included emphasis on the patient’s right to effective assessment and treatment of pain. These standards include the following:

• Patients have the right to appropriate assessment and management of their pain.

• Ongoing assessment of the existence of pain should also include the nature and intensity of the pain in all patients.

• Assessment results should be recorded in a manner that promotes regular reassessment and follow-up.

• Staff, including new clinical staff, must be oriented and competent in assessment and management of pain.

• Policies and procedures that support prescription or ordering of pain medications must be in place.

• Pain must be managed so it does not interfere with a patient’s participation in rehabilitation.

• Discharge planning should address the patient’s needs for management of pain symptoms.

• Data must be collected to monitor the appropriateness and effectiveness of the facility’s pain management plan.

Many patient misconceptions interfere with the patient’s ability to communicate pain. Examples of common patient beliefs related to pain and communicating it include the following:

• The doctor has ordered pain-relieving medication for me, which I will be given routinely.

• If I ask for something for my pain, I may become addicted to the medication.

• Sometimes it is better to put up with the pain than to deal with the side effects of the pain medication.

• I should somehow be able to control my pain. It is immature to talk about pain.

• It is better to wait until the pain gets really bad before asking for help. If I take the medication now for moderate pain, it won’t relieve severe pain later on.

• I don’t want to bother anyone—I know how busy they are.

• It’s natural for me to have pain after surgery. After a few days, I should notice it lessening.

BARRIERS TO THE ASSESSMENT AND TREATMENT OF PAIN

1. The best judge of the existence and severity of a patient’s pain is the physician or nurse caring for the patient. (Correction: The patient is the authority about his or her pain. The patient’s self-report is the most reliable indicator of the existence and intensity of pain.)

2. Clinicians should use their personal opinions and beliefs about the truthfulness of the patient to determine the patient’s true pain status. (Correction: Allowing each clinician to act on personal beliefs presents the potential for different pain assessments by different clinicians, leading to different interventions from each clinician. This results in inconsistent and often inadequate pain management. It is essential to establish the patient’s self-report of pain as the standard for pain assessment.)

3. The clinician must believe what the patient says about pain. (Correction: The clinician must accept and respect the patient’s report of pain and proceed with appropriate assessment and treatment. The clinician is always entitled to his or her personal opinion, but this cannot be allowed to guide professional practice.)

4. Comparable noxious stimuli produce comparable pain in different people. The pain threshold is uniform. (Findings from numerous studies have failed to support the notion of a uniform pain threshold. Comparable stimuli do not result in the same pain in different people. After similar injuries, one person may suffer moderate pain and the other severe pain.)

5. Patients with a low pain tolerance should make a greater effort to cope with pain and should not receive as much analgesia as they desire. (Correction: A stoic response to pain is valued in this society and many others. Research shows that clinicians often do not like patients with a low pain tolerance. However, imposing these values on the patient and withholding analgesics is inappropriate.)

6. There is no reason for patients to hurt when no physical cause for pain can be found. (Correction: Pain is a new science, and it would be foolish of us to think that we will be able to determine the cause of all the pains that patients report.)

7. Patients should not receive analgesics until the cause of pain is diagnosed. (Correction: Pain is no longer the clinician’s primary diagnostic tool. Symptomatic relief of pain should be provided while the investigation of cause proceeds. Early use of analgesics is now advocated for patients with acute abdominal pain.)

8. Visible signs, either physiologic or behavioral, accompany pain and can be used to verify its existence and severity. (Correction: Even with severe pain, periods of physiologic and behavioral adaptation occur, leading to periods of minimal or no signs of pain. Lack of pain expression does not necessarily mean lack of pain.)

9. Anxiety makes pain worse. (Correction: Anxiety is often associated with pain, but the cause-and-effect relationship has not been established. Pain often causes anxiety, but it is not clear that anxiety necessarily makes pain more intense.)

10. Patients who are knowledgeable about opioid analgesics and who make regular efforts to obtain them are “drug seeking” (addicted). (Correction: Patients with pain should be knowledgeable about their medications, and regular use of opioids for pain relief is not addiction. When a patient is accused of “drug seeking,” it may be helpful to ask, “What else could this behavior mean? Might this patient be in pain?”)

11. When the patient reports pain relief after a placebo, this means that the patient is a malingerer or that the pain is psychogenic. (Correction: About one third of patients who have obvious physical stimuli for pain (e.g., surgery) report pain relief after a placebo injection. Therefore, placebos cannot be used to diagnose malingering, psychogenic pain, or any psychological problem. Sometimes, placebos relieve pain, but why this happens remains unknown.)

12. The pain rating scale preferred for use in daily clinical practice is the Visual Analogue Scale (VAS). (Correction: For patients who are verbal and can count from 0 to 10, the Numerical Rating Scale (NRS) pain rating scale is preferred. It is easy to explain, measure, and record, and it provides numbers for setting pain management goals.)

13. Cognitively impaired elderly patients are unable to use pain rating scales. (Correction: When an appropriate pain rating scale (e.g., 0–5) is used and the patient is given sufficient time to process information and respond, many cognitively impaired elderly patients can use a pain rating scale.)

primary purposesof using a guide to assess pain

to eliminate guesswork and biases when dealing with the patient’s pain, to understand what the person is experiencing, to analyze findings that will help prepare an appropriate nursing response to the patient’s pain, and to facilitate improved outcomes, such as fewer complications, shorter hospital stays, and improved quality of life.

Characteristics of pain generally assessed include the following:

• Patient’s verbalization and description of the pain

• Duration of the pain

• Location of the pain

• Quantity and intensity of the pain

• Quality of the pain

• Chronology of the pain

• Aggravating factors

• Alleviating factors

• Physiologic indicators of pain

• Behavioral responses

• Effect of the pain experience on activities and lifestyle

When assessing an individual’s pain, McCaffery and Pasero (1999) list these basic methods:

• Patient’s self-report

• Report of family member, other person close to the patient, or caregiver who is familiar with the patient

• Physiologic measures (increased blood pressure and pulse) although most research verifies that reliance on vital signs to indicate the presence of pain should be minimized. The absence of an increase in vital signs does not mean that pain is not present.

the following observations may provide an indication of the presence and severity of pain in a child:

• Irritability and restlessness

• Crying, screaming, or other verbal expression of pain

• Grimacing, grinding of teeth, or clenching fists

• Touching or grabbing of painful body part

• Kicking, thrashing, or attempting to move away from a painful stimulus

Infants, particularly premature infants, are as sensitive to painful stimuli as older children and adults. Current thinking is that inadequately controlled pain during infancy and childhood may alter a person’s response to pain in adulthood. Pain is frustrating for children because they are unable to understand the concept and cause of pain and may have difficulty describing it. the child may see the pain as a form of punishment for something that he or she has done. It is thought that children are able to indicate that pain is present at approximately 2 years of age. Numerous scales and tools can be used to assess a child’s pain.

Wong-Baker FACES pain rating scale

asks children to compare their pain to a series of faces ranging from a broad smile to a tearful grimace. There are 6 faces, and it ranges from 0 for no pain, and from 10 for hurts worst. It's used for adults and children (3 years old) in all patient care settings

Oucher pain scale

for use in young pts, combines a 0-to-100 scale with 6 photographic images of children in pain. This scale is helpful for use with older children. Adaptations of the Oucher pain scale are also available for various ethnic groups. Young children who can point to a face to indicate their level of pain.

CRIES Pain Scale

is a tool intended for use with neonates and infants from 0 to 6 months.

COMFORT Scale

used to assess pain and distress in critically ill pediatric patients relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. For infants, children, and adults who are unable to use NRS or Wong–Baker FACES Pain Rating Scale.

FLACC scale

(F – Faces, L – Legs, A – Activity, C – Cry, C –Consolability) designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain rates each of the five categories on a 0-to-2 scale. Additionally, children may be asked to record their pain experiences in a daily diary. Detecting and accurately assessing pediatric pain have resulted in new and innovative approaches toward pain control in children.

A recent study documented efforts to identify the presence of pain in preterm neonates who were on a ventilator. Facial expressions, high activity level, and poor response to handling were viewed as indicators of the presence of pain in this population.

Pain Assessment in Advanced Dementia scale (PAINAD)

has been developed to assess pain in this population. It relies on observation of five specific items: breathing, vocalization, facial expression, body language, and consolability.

Assessment of pain in the older adult can be problematic. Visual or hearing impairments may influence the assessment format. Multiple-drug regimens that are common in older people can also affect reliable reporting of pain. One myth held by many is that older patients have a decreased sensitivity to pain and, therefore, a heightened pain tolerance. Pain is seen by many elderly patients as a forecast of serious illness or death. Boredom, loneliness, and depression may affect an older person’s perception and report of pain. Experts agree that pain can be adequately assessed in most older adults using common rating scales. The Wong-Baker FACES Pain Rating Scale, recommended for pain assessment in children, may also be effective for this age group because a 0-to-5 scale is easier to use. The Numeric Rating Scale, the verbal descriptor scale, and the Faces Pain Scale-Revised (FPS-R) are additional pain rating scales that are also widely used for assessing pain in older adults.

When a nursing diagnosis of acute or chronic pain is developed, the diagnostic statement and plan of care should identify the following:

For patients whose pain is chronic in nature, an expected outcome may be contacting a hospice or a pain clinic. Hospice care addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families in either the home or a hospice center. Pain relief is a priority in this setting. Numerous outpatient centers are also available to support patients with chronic pain and to improve their pain management through a variety of approaches. The physician, nurse, and other members of the healthcare team collaborate to develop the optimal pain-treatment plan for each patient with chronic pain.

Pain tolerance

is the point beyond which a person is no longer willing to endure pain. These factors should be alleviated whenever possible. For example, patients whose families have never acknowledged their pain and who have repeatedly been told that their pain is all in their head may experience a greater ability to deal with their pain when someone finally takes the pain seriously. Nursing measures include communication to the patient that responses to pain are acceptable and education of the patient’s family.

Fatigue tends to increase pain; therefore, promoting rest is helpful. Although sensory restrictions, such as eliminating unnecessary noise and bright lights, are usually indicated, it is rarely helpful to leave the patient alone in an environment with little sensory input. The patient is then more likely to focus on self and the discomfort.

Lack of knowledge, finding no meaning in the pain, being pessimistic about its relief, and fear may also interfere with the patient’s ability to deal with pain. Common fears include a loss of control and embarrassment by being unable to deal with the pain maturely. Another fear may be a fear of taking pain relief medication. The patient may view the need for medication as a sign of weakness or may fear addiction or loss of the effectiveness at a later date. Older patients, in particular, are frequently frustrated by similar concerns about pain management.

Distraction

Conscious attention often appears to be necessary to experience pain, whereas preoccupation with other things has been observed to distract the patient from pain. Distraction requires the patient to focus attention on something other than the pain. It is not entirely clear whether distraction raises the threshold of pain or increases pain tolerance. Many patients whose pain is relieved by distraction report being able to place pain in the periphery of awareness. This is compatible with the theory that if the reticular formation in the brainstem receives sufficient sensory input, it can ignore or block out select sensations such as pain. The Lamaze method of childbirth is one common example involving the use of distraction. Distraction alone may relieve mild pain. However, it is most effective when used before pain begins or soon thereafter. It has also been proven effective when used with analgesics for treatment of a brief episode of severe pain (e.g., pain that accompanies a diagnostic procedure). Distraction may also be used successfully with children.

• Project distractions: playing a challenging game, performing meaningful play or work

Humor

Humor can be an effective distraction, can help an individual cope with pain, and may even have a positive effect on the immune system. It has been proven particularly effective before painful procedures, and many pain, cancer, and ambulatory care centers encourage patients to view humorous videos before a painful, tedious procedure. Remember to use humor only with patients who are responsive to its use and wish to use it. Humor should not be used in patients with moderate to severe pain, nor should it be a replacement for pharmacologic analgesia. In addition, humor must be patient specific. Thus, the nurse will need to determine what makes a patient laugh, how the patient has used humor or play in the past, and how it helped. Let the patient select the humorous materials, and when possible, incorporate strategies that include the patient’s family and friends.

Laughter causes the following physiological and psychological effects:

• Decreases levels of epinephrine (the stress hormone)

• Activates the immune system

• Elevates the threshold for pain and can minimize the pain sensation

• Promotes spiritual and psychological coping

• Helps one to face difficult or unpleasant procedures

• Creates a more positive atmosphere

• Increases heart rate and stimulates circulation

• Deepens respirations

• Causes muscles to contract

Listening to music

Listening to music can relax, soothe, decrease pain, and provide distraction. By stimulating the release of endorphins, music enhances one’s sense of well-being and decreases the need for pain medication. Patients can select the music they prefer to be used for relaxation before, during, and after surgical experiences, or to help focus on breathing techniques during labor. Some evidence has indicated that music may be effective for soothing agitated newborns and comatose patients.

using imagery

Patients who use imagery (an example of mind–body interaction) to decrease pain sensation imagine something that involves one or all of the senses, concentrate on that image, and gradually become less aware of the pain. Imagery may be as simple as a child thinking of “happy things” (a beloved pet, lollipops, Christmas morning, Grandmom’s lap), or as involved as an adult recreating a favorite place and then experiencing the healing presence or touch of a loved person or the healing energies of nature in that setting. The imagery technique has also been used to create an image in which the cause of the pain is visualized and then overcome or counteracted by some more powerful image. Imagery has been found to be more effective for patients with chronic pain than for patients with acute, severe pain. If the patient becomes restless or upset, the imagery experience is terminated and attempted later when the patient seems better disposed.

General techniques for successfully guiding a patient to use imagery include the following:

• Help the patient to identify the problem or goal.

• Suggest that the patient begin the imagery with several minutes of focused breathing, relaxation, or meditation.

• Help the patient to develop images of the problem, as well as personal internal resources (e.g., coping strategies) and external healing therapies (e.g., medications, treatments).

• Encourage images of the desired state of well-being at the end of the session.

Relaxation techniques

Relaxation techniques reduce skeletal muscle tension and lessen anxiety. By assisting the patient with relaxation techniques, the nurse acknowledges the patient’s pain and expresses a willingness to help the patient relieve the distress caused by his or her pain. Relaxation is most effective as a pain relief measure when combined with slow, deep, easy breathing from the abdomen or diaphragm, with the patient’s eyelids closed or with the individual focusing on a real or imagined fixed spot. Researchers who studied the effect of relaxation measures for pain relief have reported that progressive muscle relaxation seems to have a positive effect on arthritis pain. Support was also found for the use of jaw relaxation and systematic relaxation techniques for relieving postoperative pain.

The positive effects of relaxation for the person with pain include the following:

• Improved quality of sleep

• Distraction from the pain

• Decreased fatigue

• Increased confidence and sense of self-control in coping with pain

• Lessening of the detrimental physiologic effects of continued or repeated stress from pain

• Increased effectiveness of other pain relief measures

• Improved ability to tolerate pain

• Decreased distress or fear during anticipation of pain

• Reassurance that the nurse is aware of his or her problem and wants to help

cutaneous stimulation

The success of cutaneous stimulation (techniques that stimulate the skin’s surface) in relieving pain is often explained using the gate control theory. The gate control theory of pain postulates that cutaneous nerve fibers are large diameter fibers carrying impulses to the CNS. When the skin is stimulated, pain is believed to be controlled by closing the gating mechanism in the spinal cord. This decreases the number of pain impulses that reach the brain for perception. These techniques can be used in all healthcare settings to supplement a pain-control regimen.

a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body’s release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care.

TENS

is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful impulses carried over small-diameter fibers. The TENS unit consists of a battery-powered portable unit, lead wires, and cutaneous electrode pads that are applied to the painful area. The use of TENS requires a physician’s order. TENS therapy has reportedly been effective in reducing postoperative pain and improving mobility after surgery. Positive results have also been noted when it is used as an adjunct with physical therapy and for patients with low back pain. The TENS unit may be applied intermittently throughout the day or worn for extended periods of time, depending on the physician’s order. Use of cutaneous stimulation is limited because the pain must be localized. Otherwise, it is most likely too diffuse to be effective. In addition, most individuals cannot tolerate stimulation of the painful area; they may, however, be helped by stimulation of the surrounding or contralateral area.

Acupuncture

is a technique that uses needles of various lengths inserted into specific parts of the body to produce insensitivity to pain. The technique was developed in China and has been used for centuries in many Asian countries. It has gained acceptance in the Western world as an alternative intervention to help control discomfort from disorders such as headaches, menstrual cramps, postoperative dental pain, low back pain, and carpal tunnel syndrome. The relief of pain by acupuncture is generally explained on the basis of the gate control theory. Self-hypnosis may also account for some of acupuncture’s success. Repeated treatments are often needed.

Percutaneous electrical nerve stimulation (PENS)

is a complementary therapy used particularly for the management of acute and chronic pain syndromes. This form of acupuncture combines the advantages of both electroacupuncture and TENS and consists of needle probes being placed into soft tissue to stimulate peripheral sensory nerves that relate to the area of injury or pain. The electrical stimulus that is delivered by passes the skin barrier and goes directly to the involved nerve. PENS has been shown to be effective when dealing with chronic low back pain as well as diabetic neuropathy pain.

Hypnosis

a technique that produces a subconscious state accomplished by suggestions made by a hypnotist, has been used successfully in many instances to control pain. The person’s state of consciousness is altered by suggestions so that pain is not perceived as it normally would be. According to many hypnotists, it also alters the physical signs of pain. Many people can be taught autohypnosis, that is, self-induced hypnosis, for the control of pain. It is generally believed that a successful response to hypnosis is related to the individual’s openness to suggestion, belief that hypnosis will work, and emotional readiness.

Biofeedback

Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the patient’s skin. The feedback signal or unit transforms the physiologic data into a visual display. Upon seeing pain-related responses, such as increased muscle tension or elevated blood pressure, the patient is taught to regulate this physiologic response and control pain by practicing techniques such as deep-breathing exercises, progressive relaxation exercises, or visual imagery. Biofeedback decreases the individual’s pain by reducing the anxiety associated with lack of control over bodily functions, distracts the person’s attention from the pain to concentration on the person’s inner state and the feedback signal, and reduces the cause of the pain. Eventually, the desired effect is for an individual to produce the expected effect without the use of the biofeedback machinery. Limitations of this method include the high degree of motivation needed and difficulty of maintaining control after the training program

Therapeutic Touch

is an alternative therapy that involves using one’s hands to direct an energy exchange consciously from the practitioner to the patient to facilitate healing or pain relief. It is viewed by many as a powerful adjunct to pain relief therapy. Patients who have received therapeutic touch state that it helps with feelings of comfort, calmness, and well-being. It is derived from the ancient practice of laying on of hands, but nurses skilled in Therapeutic Touch never actually touch their patients when using this technique. Therapeutic Touch was developed by nurses, does not require a physician’s order, and can be used in any setting. Nurses caring for patients with terminal diseases relate that therapeutic touch complements their efforts to alleviate suffering and can be used to promote comfort during the final stages of life.

analgesic

is a pharmaceutical agent that relieves pain. Analgesics function to reduce the person’s perception of pain and to alter the person’s responses to discomfort.

are generally considered the major class of analgesics used in the management of moderate to severe pain because of their effectiveness. In sufficient dosage, they are considered capable of relieving pain of virtually every nature. Opioids produce analgesia by attaching to opioid receptors in the brain. New research on pain management has indicated that a person’s response to opioids may be affected by individual differences in opioid binding sites. Enzymes that promote binding at a site may be missing meaning that less of the particular opioid will bind to the site and be activated. This is referred to as opioid polymorphism and may explain why responses vary to specific opioid medication. The most common side effects associated with opioid use are sedation, nausea, and constipation. Most side effects disappear with prolonged use, but if constipation persists, it usually responds to treatment with increased fluids and fiber and use of a mild laxative or stool softener. Respiratory depression is a commonly feared side effect of opioid use. In reality, it is an uncommon occurrence in long-term therapy because patients have usually developed a tolerance to the drug and its respiratory depressant effects. If respiratory depression is suspected, it is usually preceded by sedation. Nursing assessment using the numeric sedation scale can determine those patients at risk for respiratory depression.

Morphine

the prototype opioid, is available in multiple dosage forms, has a fairly predictable action, and is relatively inexpensive.

The numeric sedation scale is as follows:

• 1 awake and alert; no action necessary

• 2 occasionally drowsy but easy to arouse; requires no action

• 3 frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose

• 4 somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone

If respiratory depression is suspected and the opioid dose is withheld, the patient may be physically stimulated by shaking or using a loud sound, along with reminders every few minutes to breathe deeply. If this is ineffective, naloxone (Narcan), an opioid antagonist that reverses the respiratory depressant effect of an opioid, can be used. Naloxone is administered intravenously at a very slow rate. Within 1 to 2 minutes, the patient usually opens his or her eyes and is able to respond to the nurse. When the patient is alert again and the respiratory rate is greater than 9 breaths/min, the opioid may be resumed.

Many myths and irrational fears persist concerning the use of opioid analgesics. Patients and caregivers cite fear of addiction as a reason for ineffective treatment of pain. Because of this, nurses are concerned about administering prescribed doses of opioids, physicians underprescribe pain medication, and patients refuse or take less than prescribed doses of the drugs. Physical dependence and tolerance are frequently confused with addiction.

Physical dependence

is a phenomenon in which the body physiologically becomes accustomed to the opioid and suffers withdrawal symptoms if the opioid is suddenly removed or the dose is rapidly decreased.

Tolerance

occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief.

Addiction

is a pattern of compulsive opioid use for means other than pain control.

the four characteristics that define addiction are

craving for the substance, compulsive use, lack of control over the drug, and continued use despite harm.

Less than 1% of patients with pain become addicted to opioids, yet many nurses surveyed seriously overestimated the likelihood of addiction when opioids are used for pain relief. In reality, physical dependence and tolerance are expected responses; patients treated with opioids for pain rarely develop addiction. The tolerance and physical dependence that can occur after 4 weeks of regular opioid use and result in a decrease in analgesic effect can be treated by increasing the dose until pain control is again apparent.

important factors to consider when administering an opioid analgesic include:

• the patient’s pain rating

• the sedation level

• the patient’s comfort-function goal (the pain rating that allows a patient to perform necessary or desired activities)

Nonopioid analgesics

such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for mild to moderate pain. The simplest dosage schedules and least invasive pain management modalities should be used first. Many times, these drugs alone can provide adequate pain relief. Many of these medications are over-the-counter (OTC) products, whereas some are available by prescription only. Some can cause gastric side effects, but these symptoms may be preventable if the drug is taken with food or antacids. NSAIDs also have an anti-inflammatory effect. Individual responses to the NSAIDs vary, but these agents are contraindicated in patients with bleeding disorders (their action may interfere with platelet function) or probable infections (NSAIDs can mask the signs of an infection). An FDA advisory committee has recommended that the labels on all NSAIDs warn the consumer about the potential for gastric bleeding if certain risk factors are present and the caution that NSAIDs should be taken for the shortest times needed. The combination of nonopioid analgesics and opioids provides more analgesia than either drug taken alone.

COX-2 inhibitors

a class of NSAIDs, have a lower risk of gastrointestinal bleeding but are thought to significantly increase cardiovascular risks. Two of the COX-2 inhibitors, rofecoxib (Vioxx) and valdecoxib (Bextra), have been withdrawn from the market because of increased evidence of adverse cardiac events. Celecoxib (Celebrex), another COX-2 inhibitor, is available in the United States and used for treatment of osteoarthritis and rheumatoid arthritis. The recommendation is that NSAIDs appear to be safe in low doses for short periods of time.

Adjuvant drugs

are typically used for other purposes but are also used to enhance the effect of opioids by providing additional pain relief. They may also reduce side effects from prescribed opioids or lessen anxiety about the pain experience. Research has indicated that antidepressants and anticonvulsants are also effective for neuropathic pain.

The following guidelines are recommended for effective, individualized pain management in any setting:

• Review the pain scale of choice thoroughly.

• Discuss the benefits of using a pain scale.

• Try various pain control measures.

• Use pain control measures before pain increases in severity.

• Ask the patient what has proved effective for pain relief in the past.

• Select and modify pain control measures based on the patient’s response.

• Encourage the patient to try the pain treatment several times before labeling it ineffective.

• Be open-minded about alternative pain relief strategies.

• Be persistent.

• Be a safe practitioner.

In the home, oral morphine is still the drug of choice to control chronic pain and to control moderate severe acute pain. This method is less expensive and easy to administer, but requires that the patient is able to swallow and retain food and fluids.

Pain diaries

provide a method for individuals to document their particular pain experience, list medication or alternative therapies that were used to treat the pain, and record their effectiveness. Attempts to recallparticular aspects of a painful experience are not alwaysaccurate. Pain diaries can be used in a variety of settings and help improve the overall management of pain. Effective patient and family teaching is the cornerstone of pain relief therapy in the home.

A p.r.n. (as needed) drug regimen

has not been proven effective for people experiencing acute pain. In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient. Later, however, in the postoperative course, a p.r.n. schedule may be acceptable to relieve occasional pain episodes. The p.r.n. protocol is totally inadequate for patients experiencing chronic pain.

Continuous intravenous infusion

has proved effective for the relief of acute postoperative pain, such as patient-controlled analgesia and epidural analgesia.

has been shown to offer superior pain management for chronic cancer pain. Long-acting controlled-release oral morphine or oxycodone or use of a fentanyl patch have been proven effective for this type of pain. The FDA issued its second warning regarding safe use of the fentanyl patch. It is intended for use in patients who are opioid-tolerant and havechronic pain; it should not be used to treat acute pain. Patients need instruction to apply the patch according to the time interval prescribed, avoid the application of heat in areas where the patch is in place, and dispose of used patches appropriately.

Breakthrough pain (BTP)

is a temporary flare-up of moderate to severe pain that occurs even when the patient is taking ATC medication for persistent pain. This pain is often not diagnosed correctly and is frequently undertreated. Breakthrough pain can be classified as incident pain (e.g., pain caused by movement), idiopathic (spontaneous pain due to an unknown cause), or end-of-dose pain, where the pain occurs before the next dose of analgesic is due. Although it usually occurs in patients with chronic pain, it can occur in acute situations, such as a patient with postoperative pain. Incident BTP is treated more effectively with supplemental doses of a short-acting opioid taken on a p.r.n. or “as needed” basis, rather than with an increase in the dose of the ATC medication or shortening of the interval between doses, which typically is more effective with end-of-dose pain. However, the treatment for idiopathic BTP is more difficult and usually requires adjustment of the dose and dosing interval to relieve this pain. Effective management of BTP requires a medication with rapid onset and short duration of effect.

APP (assume pain present)

In situations where the patient is unable to report the presence of pain (e.g., an unconscious patient), the nurse needs to consider pain relief if a procedure is planned that normally elicits a complaint of pain. This could include turning a patient or a dressing change. In this case, the acronym APP (assume pain present) should be documented. In some instances, for example, if the patient is unable to communicate verbally but capable of some response, it may be necessary to provide a method for the patient to indicate that pain is occurring during a procedure. The simple raising of a finger or hand or squeeze of a squeak toy can alert the caregiver that analgesia is needed.

Multiple studies have reported that racial differences exist when opioids are prescribed for pain control. Black and Hispanic patients were 8% less likely than white patients to receive opioids for treatment of acute pain. Gender can also be a factor. For example, a study reported that a group of physicians in one study were more likely to prescribe optimal pain medication for men versus woman following surgery.

The major principles that guide treatment for cancer or chronic pain include:

• Giving medications orally, if possible.

• Administering medication ATC rather than on a p.r.n. basis.

• Adjusting the dose to achieve maximum benefits with minimal side effects.

• Allowing patients as much control as possible over their medication regimen.

opioid contracts

These written agreements--for pts with chronic pain--document the person’s informed consent, define treatment goals, and outline the risks and goals associated with opioid therapy. They are not legally binding but encourage patients to follow prescribed protocols.

The WHO three-step pain relief ladder

In an effort to alleviate unnecessary pain and suffering, the World Health Organization (WHO) devised a three-step analgesic ladder that recommends the appropriate progression of drugs and dosages that should be used to manage chronic pain effectively. Emphasis is on individualizing treatment and using the analgesic ladder to provide attentive, aggressive pain relief. The effectiveness of the WHO analgesic ladder is widely acknowledged, and this regimen provides relief to 70% to 90% of patients with cancer pain. Some clinicians have suggested that the WHO three-step analgesic ladder may require some adjustment based on the clinical experience that has occurred in the 20 years since the ladder was proposed. The 10% to 30% of patients with severe pain who do not obtain satisfactory pain relief using this guideline may require alternative routes of drug administration, nerve blocks, or other invasive procedures to relieve their pain. Study continues in an effort to provide the data needed to effect a change or adjustment if one is justified in the WHO analgesic ladder.

In postoperative situations, children need analgesics ATC or by continuous infusion. Opioids are the drug of choice for moderate to severe pain. Pain management for cancer pain or chronic pain in children follows the prescription outlined in the WHO analgesic ladder. Withholding opioid drugs from children with cancer because of fear of addiction is unjustified because current knowledge does not indicate they are vulnerable to this problem. Children also require pain management to minimize or alleviate the pain and distress associated with some procedures. The misconception persists that children experience pain differently; if a procedure is painful for an adult, then it is also painful for a child. Adequate education before the procedure and using drug and nondrug therapies to complement each other can take the pain and fear out of the experience. This is especially important for children with a chronic disease who must undergo multiple procedures as part of the treatment regimen.

Recommendations for analgesic administration for older adults include the following:

• Acetaminophen may be used cautiously for mild to moderate pain. NSAIDs have the potential for renal and gastric complications and a proton pump inhibitor should also be prescribed.

• Administer medications, if possible, via the oral route.

• Use IM and IV analgesics cautiously because decreased circulation poses a risk for reduced absorption of opioids

NURSING STRATEGIES TO ADDRESS PHYSIOLOGICCHANGES AFFECTING COMFORT

Communication Difficulties:

• Observe carefully for any behavioral manifestations or indications of pain (e.g., change in activity level or grimacing with movement).

• Use open-ended questions to solicit information about pain.

• Rely on family or caregiver to assist with information-gathering process.

• Monitor for any behavior changes or confusion after medication has been taken.

Denial of Pain:

• Clarify terms used to describe pain or discomfort.

• Emphasize importance of reporting pain to caregivers.

• Express concern about pain and a willingness to help. Explain that pain is not a normal consequence of aging.

Altered Physiologic Response to Analgesics: • Be aware of dosage and frequency to avoid oversedation and toxicity.

• Monitor carefully for oversedation and respiratory depression.

• Explain side effects of analgesics to patient.

• Use memory aid if necessary to avoid overdosing.

• Discourage self-medication.

• Caution about use of alcohol with analgesics.

• Caution about driving or operating machinery when taking analgesics.

Patient-controlled analgesia (PCA)

provides effective individualized analgesia and comfort. This method of analgesia therapy may be used to manage acute and chronic pain in a healthcare facility or the home. PCA effectively relieves pain associated with operative procedures, labor and delivery, trauma situations, and cancer. This device is most commonly used to deliver analgesics intravenously or via the epidural route. The most frequently prescribed drugs for PCA administration are morphine, fentanyl, and hydromorphone.The PCA system consists of a computerized portable infusion pump containing a chamber for a bag or syringe that is prefilled with the prescribed opioid analgesic. Both the JointCommission (JC) and the Institute for Safe Medication Practices (ISMP) recommend standard doses and concentrations prepared in prefilled syringes and bags. Initially, a loading dose is administered to raise blood levels to a therapeutic level and control the pain. When the sensation of pain reoccurs, the patient pushes a button that activates the PCA device to deliver a small preset bolus dose of the analgesic. A dose interval that is programmed into the PCA unit (usually, 6–8 minutes) prevents reactivation of the pump and administration of another dose during that period of time. The pump mechanism can also be programmed to deliver only a specified amount of analgesic within a given time interval (the lock-out interval). This is most commonly every hour or, occasionally, every 4 hours. The 4-hour lockout is not viewed as favorably now because the shorter interval allows for closer monitoring of pain relief. These safeguards limit the possibility of possible overmedication. In addition, time is provided for the patient to evaluate the effect of the previous dose. PCA pumps also have a locked safety system that prohibits any tampering with the device. The proper selection of patients for PCA analgesia is vital for a positive experience. Suitable candidates for this type of delivery system include individuals who are alert and capable of controlling the unit. The Joint Commission and ISMP both identify individuals who are not recommended for this type of pain relief. These include confused elderly patients, infants and very young children, any cognitively impaired patient, those with conditions where oversedation poses a significant risk (e.g., asthma and sleep apnea), and patients who are taking other medications that potentiate opioids.

PCA has many advantages:

• Consistent analgesic blood level is maintained rather than the inconsistent analgesia obtained with periodic intramuscular injections, which results in sharp rises and falls of serum opioid levels.

• The analgesic is delivered intravenously or epidurally so that absorption is faster and more predictable than with the intramuscular route.

• The patient is in charge of the pain management program.

• The patient tends to use less medication because it is self-administered before the pain becomes too severe.

• The patient is able to ambulate earlier, which promotes less pulmonary complications.

• The patient is more satisfied and has improved pain relief.

PCA by proxy

means that someone other than the patient activates the pump, continues to be a controversial issue. Unauthorized family members or caregivers (instead of the patient) who administer PCA by pushing the dosage button can cause serious analgesic overdoses resulting in oversedation, respiratory depression, and death. Some clinicians argue that in a pediatric setting, Nurse-Controlled Analgesia or Caregiver Controlled Analgesia is appropriate. For this to be safe, rigid agency protocols need to be in place. The Joint Commission has issued a Sentinel Event Alert on patient-controlled analgesia and does not recommend PCA by proxy. It also recommends that warning labels stating, “Only the patient should press this button” be attached to PCA pumps. The Joint Commission also advises that caregivers need to carefully monitor patients for respiratory depression using pulse oximetry and capnography (measurement of carbon dioxide concentrations) as appropriate. The carbon dioxide level in a patient’s expirations can be measured by a sensor contained in a mask or nasal cannula that the patient is wearing. This provides a more reliable measure of impending respiratory depression.

Setting up the PCA system and ensuring that it is functioning properly are nursing responsibilities. Improper programming of the pump is the most common human error associated with this therapy. Both the Joint Commission and the ISMP recommend that another nurse checks the patient ID, drug dose and concentrations, PCA pump settings, and the infusion tubing and site prior to the initiation of PCA.

fentanyl iontophoretictransdermal system (ITS)

The fentanyl iontophoretictransdermal system (ITS) is the size of a credit card, has adhesive backing, and is attached to the patient’s upper arm or chest. The patient presses a button and the medication is delivered through the skin via a low-intensity direct current. Studies have indicated that pain control with this device is good to excellent.

On-Q C-bloc system

delivers a local anesthetic through a small ball connected to a catheter that is placed near an incision or nerve close to a surgical site. Patients can press a button to deliver additional doses of the local anesthetic while the catheter delivers a continuous dose that helps to prevent breakthrough pain.

Medication on Demand (MOD) device

The Medication on Demand (MOD) device is an oral PCA device attached to an IV pole and requires that the patient wear a “radio frequency identification” wristband that allows access to the MOD. In order to receive a dose of medication, the patient records his level of pain, swipes his wristband over the device, and removes a single dose once the drawer is opened. The interval between medication doses is programmed into the MOD as per the physician’s order. When this lock-out interval has passed, a green “ready light” appears on the device. Increased patient satisfaction is an expected outcome with MOD.

Epidural analgesia

can be used to provide pain relief during the immediate postoperative phase (particularly after thoracic, abdominal, orthopedic, and vascular surgery) and for chronic pain situations. Epidural pain management is also being used for children with terminal cancer and for children undergoing hip, spinal, or lower extremity surgery. It is contraindicated if the patient is unable to give an informed consent, takes systemic anticoagulants, or has a history of long-term use of aspirin products or NSAIDs. The anesthesiologist usually inserts the catheter in the midlumbar region into the epidural space between the walls of the vertebral canal and the dura mater or outermost connective tissue membrane surrounding the spinal cord. For temporary therapy, the catheter exits directly over the spine, and the tubing is positioned over the patient’s shoulder, with the end of the catheter taped to the person’s chest. For long-term therapy, the catheter is usually tunneled subcutaneously and exits on the side of the body or on the abdomen. The drug of choice is usually preservative-free morphine or fentanyl. Because the epidural space contains blood vessels, nerves, and fat, lipid-soluble fentanyl is readily dissolved and has a rapid onset of action (5 minutes) but a short duration of action (approximately 2 hours). Morphine is a hydrophilic opioid, meaning that this drug has a high affinity for water. It has a slower onset of action but may exert its analgesic effect for as long as 24 hours because it remains longer in the cerebrospinal fluid (CSF) and spinal tissue. Epidural catheters used for the management of acute pain are typically removed between 36 and 72 hours after surgery, when oral medication can be substituted for relief of pain.

with epidural analgesic nursing responsibilities vary among institutions but must include careful monitoring of the patient’s response to therapy, with particular attention to the respiratory rate and pattern. Too much narcotic or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life threatening respiratory depression. Other potential side effects include:

agents work by chemically blocking the nerve pathways involved in pain sensation and response. Many people have experienced nerve blocks during dental work, when having a wound sutured, during delivery of a newborn, or for some minor surgical procedures.

with local analgesics, nursing measures include noting any allergic responses the patient has had in the past to anesthetic agents, alerting the patient to the pain associated with the initial injection of the anesthetic if the physician does not numb the area first, offering emotional support to the patient during the procedure, observing for any untoward effects, and protecting the patient from injury until sensory and motor functions return.

Two topical anesthetic creams (EMLA, which contains 2.5% lidocaine and 2.5% prilocaine, and ELA-Max, a 4%-lidocaine cream) provide safe, effective analgesia for children before painful procedures such as phlebotomy, lumbar puncture, or bone marrow aspiration. EMLA cream is prescribed by the physician and must be covered by an occlusive dressing for at least 1 hour before the procedure to provide local pain relief. After the time period, the cream is removed. ELA-MAX is an OTC preparation that takes effect in 30 minutes or less.

Assess and record sedation level (using a sedation scale) and respiratory status, including pulse oximetry, q1h for the first 24 hours followed by q4h intervals (or according to agency policy). Notify MD for the following: sedation rating of 3, decr in depth and respiratory rate below 8 breaths/min.

Opioids can depress respiratory center in the medulla. Change in level of consciousness is usually the first sign of altered respiratory function.

1. I have the right to have my reports of pain accepted and acted on by healthcare professionals.

2. I have the right to have my pain controlled, no matter what its cause or how severe it may be.

3. I have the right to be treated with respect at all times. When I need medication for pain, I should not be treated like a drug abuser.

placebo

comes from the Latin word meaning “I shall please.” is defined as “any medication or procedure, including surgery, that may produce an effect because of its implicit or explicit intent and not because of its specific physical or chemical properties.” The person, unaware of the placebo’s properties, may find it to be effective for the relief of pain because of the perception that it will provide comfort and because of belief in the person administering it. It is an injustice to judge a person experiencing relief from pain after the use of a placebo as a malingerer or as mentally ill. Various researchers have reported that a positive placebo effect may be related to a physiologic response (release of endorphins) or the patient’s cultural expectations, attitudes, health beliefs, or anticipation of a positive response. The use of placebos, however, raises serious ethical questions. Is lying to a patient justifiable? A nurse who administers a placebo must be willing to risk the possible consequence of the patient becoming aware of the duplicity and then refusing to trust the nurse or any other healthcare professional again. Patients who feel themselves to be in pain are vulnerable. If such a patient discovers a seeming plot to trick him or her into feeling better, it is unlikely that the patient will respect or appreciate the intentions of the physicians and nurses involved. The long-term effects of this practice far outweigh any of its benefits. The Oncology Nursing Society and the American Nurses Association in addition to other professional organizations oppose placebo use. The American Society for Pain Management Nursing (ASPMN) agrees that placebo use is fraudulent and deceptive when used to assess and treat pain but supports placebo use in clinical trials in which the patient has signed an informed consent and the institutional review board has approved the research. The nurse has firm legal and ethical grounds for refusing to administer a placebo.

Intractable pain

severe pain that is resistant to relief measures

Denial of pain may occur in older pts because they view it as an ominous sign that may interfere with their independence. Pain sensitivity may decrease with age, but even this assumption is unsafe. Pain is not a natural outcome of the aging process.

Quality refers to how the pain feels to the client or words that describe the pain's nature. Pain intensity indicates the magnitude or amount of pain perceived. It is described on a numeric scale or by terms such as none, mild, moderate, severe, or excruciating. Onset and duration are components of temporal pain pattern. Pain threshold is the amount of pain stimulation a person requires before feeling it.

The CRIES scale is appropriate for neonates (0 to 6 months). The COMFORT scale is used for infants, and adults who are unable to use other scales. The FLACC scale is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify the severity of pain and the checklist of nonverbal indicators is appropriate for adults who are unable to validate the presence of or quantify the severity of pain using either the Numeric Rating Scale or Wong-Baker Faces Pain Rating Scale.

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience. The client is not in the transduction, transmission, or perception phase of pain. Transduction phase refers to the conversion of chemical information at the cellular level into electrical impulses that move toward the spinal cord. In transmission phase, the stimuli move from the peripheral nervous system toward the brain, and the perception phase occurs when the pain threshold is reached.